Chu et al. Conflict and Health 2011, 5:12 http://www.conflictandhealth.com/content/5/1/12

RESEARCH Open Access Providing surgical care in : A model of task shifting Kathryn M Chu1,2*, Nathan P Ford1,3 and Miguel Trelles4

Abstract Background: Somalia is one of the most political unstable countries in the world. Ongoing insecurity has forced an inconsistent medical response by the international community, with little data collection. This paper describes the “remote” model of surgical care by Medecins Sans Frontieres, in Guri-El, Somalia. The challenges of providing the necessary prerequisites for safe surgery are discussed as well as the successes and limitations of task shifting in this resource-limited context. Methods: In January 2006, MSF opened a project in Guri-El located between Mogadishu and Galcayo. The objectives were to reduce mortality due to complications of pregnancy and childbirth and from violent and non- violent trauma. At the start of the program, expatriate surgeons and anesthesiologists established safe surgical practices and performed surgical procedures. After January 2008, expatriates were evacuated due to insecurity and surgical care has been provided by local Somalian doctors and nurses with periodic supervisory visits from expatriate staff. Results: Between October 2006 and December 2009, 2086 operations were performed on 1602 patients. The majority (1049, 65%) were male and the median age was 22 (interquartile range, 17-30). 1460 (70%) of interventions were emergent. Trauma accounted for 76% (1585) of all surgical pathology; gunshot wounds accounted for 89% (584) of violent injuries. Operative mortality (0.5% of all surgical interventions) was not higher when Somalian staff provided care compared to when expatriate surgeons and anesthesiologists. Conclusions: The delivery of surgical care in any conflict-settings is difficult, but in situations where international support is limited, the challenges are more extreme. In this model, task shifting, or the provision of services by less trained cadres, was utilized and peri-operative mortality remained low demonstrating that safe surgical practices can be accomplished even without the presence of fully trained surgeon and anesthesiologists. If security improves in Somalia, on-site training by expatriate surgeons and anesthesiologists will be re-established. Until then, the best way MSF has found to support surgical care in Somalia is continue to support in a “remote” manner.

Background emergencies and provoking conflicts over scarce Somalia, located in East Africa, is one of the most politi- resources. Most social services including cal unstable countries in the world. The central govern- have collapsed; under- 5 mortality rate is one in four ment collapsed in 1991 when President was and life expectancy is approximately 50 years [1]. ousted during a coup and since then civil war between Despite substantial reliance on external humanitarian various clan leaders has led to lawlessness, and insecur- assistance, ongoing insecurity has limited the ability of ity. Currently the country is divided into several parts international organizations to provide medical care as that are nearly ruled autonomously. In addition to some risks such as kidnapping are higher for expatriate ongoing insecurity, Somalia is plagued by environmental staff compared to local staff. As a consequence, there disasters such as drought and flood leading to health has been little data collection and very few reports of humanitarian assistance programmes in Somalia. * Correspondence: [email protected] Médecins Sans Frontières (MSF) has been providing 1Médecins sans Frontières, 49 Jorrisen St, Braamfontein 2017, Johannesburg, since the late 1980s. However, in South Africa Full list of author information is available at the end of the article country support has been limited in recent years due to

© 2011 Chu et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Chu et al. Conflict and Health 2011, 5:12 Page 2 of 5 http://www.conflictandhealth.com/content/5/1/12

insecurity. In order to continue to provide care in this In January 2008, MSF’s permanent expatriate presence context, some programs are managed remotely via ended due to increased insecurity. Since then, the surgi- expatriate teams located in neighboring countries such as cal program has been run remotely from Nairobi, Kenya Kenya. While limited contact with ground staff means by a team consisting of a head of mission, a medical less accountability and oversight, this is the only feasible coordinator, an administrator, and a project coordinator. way to support care in this unstable setting. This paper Visits are made to Istarlin at least twice a year in order describes the remote model of surgical care by Medecins to ensure that MSF standards, protocols, and guidelines Sans Frontieres, in Guri-El, Somalia. The challenges of are being followed in peri-operative care. providing the necessary prerequisites for safe surgery are Surgical care is provided by a Somalian doctor with discussed as well as the successes and limitations of task surgical skills who is extremely competent, especially in shifting in this resource-limited context. trauma surgery. He trained under MSF’s expatriate sur- geons for two years prior to the end of their presence. Methods He also worked with two other non-governmental orga- Somalia nizations, the International Committee for the Red The MSF healthcare response in Somalia has responded Cross and the International Medical Corps, for several to a diversity of needs, ranging from primary care and years and was mentored by expatriate surgeons. He has tuberculosis control programs to the provision of emer- attended several training seminars including a WHO gency trauma and obstetrical surgical services. Prior to surgical training course in Mogadishu. This doctor with 2008, local staff were supervised by permanent expatri- surgical skills must function independently. He does not ates, but following the killing of three staff members in perform elective surgery. Mogadishu has the closest Kismayo by a targeted roadside bomb, expatriates were referral but is over 200 km away. MSF does not prohibited from working in the country for security rea- provide ambulance services due to security constraints, sons.Currently,MSF’sprojectsinSomaliaarerunby but cases are discussed with the surgeons there. MSF local staff, with material and financial support provided surgeons are also available by email consultation. A sur- by an international co-ordination team based in Nairobi, gical nurse who has received informal on-the-job train- Kenya. ing, also performs procedures, mostly emergency obstetrics and minor operations. All anesthetics are Istarlin Hospital, Gur-El, given by anesthetic nurses. The Galguduud region is located in central Somalia and has a population of approximately 377,000. In January Data Sources 2006, MSF opened a project in Guri-El located between This review describes surgical interventions done Mogadishu and Galcayo. The objectives were to reduce between October 2006 and December 2009; all proce- mortality due to complications of pregnancy and child- dures that required anesthesia and were performed in birth and from violent and non-violent trauma. MSF the operating room were considered as surgical inter- based itself in a private facility, the 80-bed Istarlin Hos- ventions. Data was prospectively collected in an electro- pital, which received patients from the surrounding 250 nic database. Baseline characteristics on age, gender, km. The hospital operating room was in disrepair: steri- military status, and American Society of Anesthesiology lization was not properly done, and clean water and (ASA) physical status classification as well as data on electricity were not readily available. surgical pathology, procedure type, and operative mor- At the start of the program, expatriate surgeons and tality were recorded in the database at the time of the anesthesiologists established safe surgical practices. Spe- procedure. Surgical pathology was grouped into the fol- cific guidelines concerning disinfection of surgical linen, lowing categories: obstetric emergencies, infection, neo- sterilization of surgical instruments, essential medica- plasm, accidental injury, violence-related injury, and tions, blood transfusions, the organization of the surgical other. and operating theatre departments, nursing care, and the layout of the health structures were developed. Pro- Statistical analysis tocols regarding antibiotic therapy and prophylaxis, Baseline characteristics were described using medians post-operative pain management, indications for Cesar- and interquartile ranges (IQRs) for continuous variables ean section, anesthesia for pediatrics and obstetrics, and and counts and percentages for categorical data. Logistic oxygen therapy were implemented. These guidelines and regression was used to model associations with vio- protocols were used to train the local staff to manage lence-related injury. Variables considered in the analysis the surgical ward, sterilization, and the operating thea- included age, gender, military status, ASA classification, tre. Technical training in surgical and anesthesia skills and blood transfusions. Factors with a p < 0.1 on uni- were also provided. variate analysis were included in a multivariate model. Chu et al. Conflict and Health 2011, 5:12 Page 3 of 5 http://www.conflictandhealth.com/content/5/1/12

All tests and confidence intervals were considered to be 46% (46) of all Cesarean sections and 60% (35) of uter- significant at a p ≤ 0.05. All analyses were performed ine evacuations. The doctor performed the majority using STATA 10 (College Station, TX, USA). (89%, 306) of elective cases. Peri-operative mortality was lower (0.2%, 2 cases) between 2008-2009 compared to Results 2006-2007 (1.7%, 6 cases), P < 0.001). Between October 2006 and December 2009, 2086 opera- tions were performed on 1602 patients (24% re-inter- Conclusions ventions).Themajority(1049,65%)weremaleandthe There are very few published outcome reports from sur- median age was 22 (interquartile range, 17-30), with 152 gical services in war-torn resource-limited settings. In patients (6%) under 5 years of age. 20% of patients were this programme, nearly half of surgical interventions in the military. 1460 (70%) of interventions were emer- were for violence-related trauma and another third were gent. 1649 (79%) of procedures were performed under due to accidental trauma. Most interventions were rela- general anesthesia without intubation, 300 (14%) under tively minor procedures such as wound debridement, local anesthesia, 55 (3%) under spinal anesthesia, and 40 suturing, or dressing changes, with only a small number (2%) under general anesthesia with intubation. There of trauma cases requiring abdominal surgery or were 8 cases of operative mortality (0.5% of all surgical advanced orthopedic knowledge. While this may partly interventions) among which 4 were trauma- related and reflect the preference of the lesser-trained surgical staff 4 were obstetric-related. Hospital mortality was to deal with less complicated cases, the caseload is simi- unknown. lar to findings in other African district [2], and strongly suggests that in resource-limited conflict areas Surgical Pathology most surgical interventions could be performed by non- Trauma accounted for 76% (1585) of all surgical pathol- surgeons, which is an important consideration given the ogy: 45% (939) were due to violent-related injury and lack of local surgeons in resource-limited settings [3] 31% (652) due to accidental injury. Obstetrical emergen- and the danger posed to expatriate surgeons. cies accounted for 14% (284) of interventions, infection Somalia has one of the highest maternal mortality 6% (128), and neoplasms 0.3% (7). Gunshot wounds ratios in the world (> 1000 deaths per 100,000 live accounted for 89% (584) of violent injuries (Table 1). births compared to 9 per 100,000 live births in The most common non-violence-related injuries were resource-rich countries) [4] due to poor access to emer- burns and falls. Wound debridement and suturing were gency obstetric care. In this program, Cesarean sections the most common procedures for trauma. Only 7% represented a lower proportion of surgical interventions (111) of trauma cases required abdominal surgery and compared to reports from other conflict settings [5]. only 5% (73) were orthopedic related. (Table 2). Istarlin Hospital provides the only emergency obstetrical service for the region therefore patients are unlikely to Associations with Violence-related Injury be seeking care elsewhere. Currently, only 50 Cesarean Male gender (adjusted odds ratio (AOR) = 7.7, P < sections are performed annually in the Galgaduud 0.001), military status (AOR = 2.7, P < 0.001), and age > region and the estimated Cesarean rate is < 1%. The 15 years (AOR = 3.3 P < 0.001) were associated with WHO recommends that 5-15% of deliveries should be violence-related injury (Table 3). delivered by Cesarean section [6]. A lower proportion suggests that some women in the community with com- Task shifting plicated deliveries may not be accessing care. It is esti- All surgical procedures were performed by non-surgeons mated that less that 2% of deliver at (doctor with surgical skills and a surgical nurse) after a health care facility with a skilled attendant [7]. This is January 2008. From 2008-2009, the doctor with surgical likely due to a combination of factors such as lack of skills performed 1119 (78%) of procedures and the sur- facilities, insecurity of road travel, the inequality of gical nurse 314 (22%). The surgical nurse performed women, and the fear of institutional deliveries [8,9]. The reasons for such low uptake of emergency obstetrics Table 1 Causes of Violent Injury requires further investigation. The most common type of anesthesia provided in this N (%) program was general anesthesia without intubation Gunshot Wound 584 (89) which is safer than general anesthesia with intubation Knife 55 (8) for nurse-anesthetists or anesthesia providers that are Torture 12 (2) informally trained. However, the proportion of cases Bombs 6 (1) performed under spinal anesthesia was low and this was Total 657 100 likely due to the inexperience of the practitioners. More Chu et al. Conflict and Health 2011, 5:12 Page 4 of 5 http://www.conflictandhealth.com/content/5/1/12

Table 2 Trauma and Non-Trauma Related Interventions Trauma N (%) Non-Trauma N (%) Wound Debridement 674 (42) Cesarean section 161 (33) Suturing 465 (29) Suturing, I and D, Circumcision 85 (17) Abdominal Surgery/Bowel Resection 111 (7) Wound Debridment 55 (11) Dressing Changes under Sedation 75 (5) Dressing Changes under Sedation 28 (6) Fracture Reductions 56 (4) Abdominal Surgery* 20 (4) Amputations 17 (1) Tubal ligation/Dilation and curettage 19 (4) Skin Grafts 7 (0.5) Minor Surgery** 12 (2) Other 143 (9) Other 39 (8) Total 1591 (100) Total 495 (100) *Bowel resection, appendectomy, tumour resection. **Herniorraphy, hydrocelectomy, hemmorrhoidectomy. training is needed to increase the capacity of the anes- be successful, several conditions are required such as thetic nurses. regular supervision and exposure to technologic updates. Task shifting is an essential component of this pro- Any practitioner working in isolation can fall into the gram. For the past three years, surgical services have trap of inadvertently making the same mistakes and been provided by non-surgeons (a doctor with surgical developing improper techniques and/or make incorrect skills and a surgical nurse) and anesthesia by non- decisions. For the Somalian doctor and nurse, options anesthesiologists (anesthetic nurses). Such task shifting for supervision are limited in county, and it is currently was a consequence of the high insecurity in Somalia, as too dangerous for expatriate surgeons to make field vis- most surgical programmes run by MSF involve expatri- its for any length of time to do meaningful training. ate surgeons and anesthesiologists. However, task shift- MSF is providing them additional training in Kenya. ing is increasingly acknowledged as being an important While it is difficult to evaluate the quality of surgical approach to overcoming specialized human resource care, this report shows that the peri-operative mortality, shortages more generally: specialist physicians such as a crude measure of the quality of surgical services, was surgeons and anesthesiologists are scarce in sub-Saharan not higher after expatriates left the program (in fact, it Africa [3], and in many settings non-surgeons are decreased). This demonstrates that safe surgery is possi- responsible for providing the majority of surgical care ble while task shifting and in this resource-limited [10]. The types of procedures performed are limited setting. both by the technology and equipment available as well The delivery of surgical care in any conflict-settings is as the skills of these practitioners. In certain countries, difficult, but in situations where international support is specific surgical procedures such as emergency obstetri- limited, the challenges are more extreme. However, in cal care or orthopedic trauma are safely performed settings that are too insecure to provide permanent on- safely performed by non-doctors [11-14]. In low-income the ground support, the remote model is a feasible way settings such as Niger, Malawi, and Mozambique, surgi- to deliver emergency surgical services. In our program, cal task-shifting has resulted in an increased provision logistical and financial support was provided from in essential surgical services [15,16]. For task shifting to neighboring (more stable) Kenya. Task shifting, or the provision of services by less trained cadres, was utilized Table 3 Associations with Violence-related Injury and peri-operative mortality remained low demonstrat- Univariate Multivariate ing that safe surgical practices can be accomplished even without the presence of fully trained surgeon and OR 95% CI P OR 95% CI P anesthesiologists. Well-established protocols and guide- lines helped maintain the quality of care. The remote Female 1.0 model of surgery lacks regular oversight by fully trained Male 9.9 (7.5-13.2) < 0.001 7.7 (5.6-10.8) < 0.001 surgeons and anesthesiologists, so evaluations and train- ings can only be carried out a few times a year. The Age < 15 years 1.0 program could be improved with more training of Age ≥ 15 years 3.8 (2.8-5.2) < 0.001 3.3 (2.3-4.7) < 0.001 Somalian staff; discussions are already underway for extra surgical and anesthesia training outside Somalia Civillian 1.0 for the doctor and nurses. Live consultations via video- Military 6.3 (4.7-8.6) < 0.001 2.7 (1.9-3.7) < 0.001 conferencing for difficult cases would also be beneficial. Chu et al. Conflict and Health 2011, 5:12 Page 5 of 5 http://www.conflictandhealth.com/content/5/1/12

If security improves in Somalia, permanent expatriate emergency obstetric surgery by clinical officers and medical officers in Malawi. Human resources for health 2007, 5:17. presence will be re-established. Until then, the best way 13. Pereira C, Cumbi A, Malalane R, Vaz F, McCord C, Bacci A, Bergstrom S: MSF has found to support surgical care in Somalia is Meeting the need for emergency obstetric care in Mozambique: work continue to support in a “remote” manner. performance and histories of medical doctors and assistant medical officers trained for surgery. Bjog 2007, 114:1530-1533. 14. Wilson A, Lissauer D, Thangaratinam S, Khan KS, Macarthur C, Coomarasamy A: A comparison of clinical officers with medical doctors Acknowledgements on outcomes of caesarean section in the developing world: meta- The authors would like to thank the MSF field team in Guri-El, Somalia and analysis of controlled studies. BMJ 2011, 342:d2600. the staff from Istarlin hospital for their excellent work and dedication to their 15. Sani R, Nameoua B, Yahaya A, Hassane I, Adamou R, Hsia RY, Hoekman P, patients. In particular, we thank Barut Matan for his clinical and data Sako A, Habibou A: The impact of launching surgery at the district level collection services. in niger. World journal of surgery 2009, 33:2063-2068. 16. Mkandawire N, Ngulube C, Lavy C: Orthopaedic clinical officer program in Author details Malawi: a model for providing orthopaedic care. Clinical orthopaedics and 1Médecins sans Frontières, 49 Jorrisen St, Braamfontein 2017, Johannesburg, related research 2008, 466:2385-2391. South Africa. 2Departments of Surgery and International Health, Johns Hopkins University, Baltimore, MD, USA. 3Faculty of Health Sciences, Simon 4 doi:10.1186/1752-1505-5-12 Fraser University, Vancouver, Canada. Médecins sans Frontières, rue Dupré Cite this article as: Chu et al.: Providing surgical care in Somalia: A 94, 1090 Brussels, Belgium. model of task shifting. Conflict and Health 2011 5:12.

Authors’ contributions KC, PN, NF, and MT were responsible for the overall concept and design. KC, PN, and MT contributed to the data collection and analysis. KC, NF, and MT contributed to intellectual content, and writing of the paper. KC wrote the first draft of the paper. All authors reviewed and approved the final version of the paper.

Competing interests The authors declare that they have no competing interests.

Received: 16 March 2011 Accepted: 15 July 2011 Published: 15 July 2011

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